In the Western world liver cirrhosis is one of the leading causes of death right after cardiovascular disease and cancer. Among people aged 45 to 65 it is the 3rd leading cause of death. The tragedy is that most of these cases of liver cirrhosis are preventable and most of them are cirrhosis due to alcohol abuse. In other parts of the world where hepatitis B runs rampant cirrhosis of the liver is due to the chronic scarring from infectious hepatitis.
Hepatitis C is emerging from the intravenous drug use with contaminated needles and this will develop into cirrhosis of the liver in virtually all cases in the long-term.
Lately, with obesity being more common, a new cause of getting liver cirrhosis has emerged. People get the reversible fatty liver disease (also known as “nonalcoholic fatty liver disease” or NAFLD) where fat is incorporated into the tissue of the liver. This is associated with diabetes, the metabolic syndrome, as well as elevated cholesterol and lipids. When any of these are also present with fatty liver disease an inflammatory condition of the fatty liver leads to nonalcoholic steatohepatitis (=NASH). In a Danish study patients with NAFLD were observed for 17 years and less than 1% developed cirrhosis of the liver. However, 1 in 4 patients with NASH (liver cirrhosis that developed out of a fatty liver) will die within 5 years with liver-related complications. In this context it is important to know that 2 to 3% of adults in the US have NASH and 20% of these will develop liver cirrhosis (Ref. 9).
In a recent trial two 750mg capsules of cinnamon were given to the experimental group with NAFLD while a placebo group received inert capsules. There was an astounding improvement in inflammatory markers and liver function tests in the cinnamon group.
Chronic biliary obstruction ( for instance from gall stones) is another important reason to develop cirrhosis of the liver.
The surface of the liver is knobbly instead of shiny and smooth. This can be seen on this image of a liver with cirrhosis. With end stage cirrhosis of the liver patients develop portal hypertension. This is a condition where the blood, which normally flows from the veins of the bowels to the liver will not be able to get into the liver and thus experiences an increase in pressure in that system (hence the name”portal hypertension”). Venous escape routes get established in these patients, namely via the lower esophageal veins(esophageal varices), the rectal veins and the periumbilical veins.
Many patients are asymptomatic for several years. The first symptoms may be weight loss, lack of appetite, nausea and weakness. In patients with biliary obstruction there often is a chronic skin itch, which leads to an intractable and very annoying itching leaving scratch marks all over the body. Jaundice from backed-up bile salts can be seen in the skin in more advanced cases.
With a cirrhosis based on chronic alcohol abuse there may be signs of malnutrition with wasted muscles and symptoms from chronic pancreatic insufficiency (due to chronic pancreatitis). Portal hypertension is common in these patients and often these patients will die from a sudden massive bleed from ruptured esophageal varices. Other complications are the development of ascites( free watery fluid in the abdomen), liver failure with metabolic derangement and systemic bleeding from a lack of clotting factor production by the cirrhotic liver. Hepatic encephalopathy is another late symptoms where confusion sets in and thought processes are severely disturbed and behaviors grossly out of control. This can create severe commotions in the hospital setting, at home or wherever they are.
Before liver transplants had been available for end stage liver cirrhosis, there was no cure and only symptomatic therapy could be offered.
Now the gastroenterologist will follow these patients and symptomatically treat the various symptoms until the stage, beyond which the complication rate becomes unacceptable and a liver transplant is suggested. Pruritus (= itchy skin) can be relieved with cholestyramine. Toxic substances such as alcohol should be removed whenever possible.
Proper nutrition, if this was a problem needs to be reestablished. In some autoimmune induced cirrhosis cases there might be a place for azathioprine. For chronic hepatitis C patients interferon-gamma has been used with some success. Eventually the gastroenterologist will likely recommend at least to some patients a liver transplant. This is not an instant cure, as following this procedure the patient has to be available for regular follow-up visits with occasional laparoscopic liver biopsies to monitor immune rejection and treat this with immunosuppressant medication. The transplantation team subjects the potential liver transplant recipient to screening tests in order to establish the suitability of the person. Transplantation is not for everyone. However, the alternative is premature death.
When “nonalcoholic fatty liver disease” (=NAFLD) is treated with aggressive weight loss measures and calorie restriction, nonalcoholic steatohepatitis (=NASH) and liver cirrhosis can be prevented.
Prevention of liver cirrhosis
In June of 2006 an article in the Archives of Internal Medicine described a protective effect of drinking coffee every day to protect from liver cirrhosis. Each cup of coffee per day had a protective effect of 22% over a 7 year observation period. This effect was absent for tea drinkers. See details here.
1. DM Thompson: The 46th Annual St. Paul’s Hospital CME Conference for Primary Physicians, Nov. 14-17, 2000, Vancouver/B.C./Canada
2. C Ritenbaugh Curr Oncol Rep 2000 May 2(3): 225-233.
3. PA Totten et al. J Infect Dis 2001 Jan 183(2): 269-276.
4. M Ohkawa et al. Br J Urol 1993 Dec 72(6):918-921.
5. Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc., pages 976-983: “Chapter 107 – Acute Abdomen and Common Surgical Abdominal Problems”.
6. Marx: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc. , p. 185:”Abdominal pain”.
7. Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier, p. 71: “Chapter 4 – Abdominal Pain, Including the Acute Abdomen”.
8. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
9. Metabolic Syndrome Rounds, St. Michael’s Hospital , Toronto/ON, Canada; March 2006, Vol. 4, Issue3.
10. Suzanne Somers: “Breakthrough” Eight Steps to Wellness– Life-altering Secrets from Today’s Cutting-edge Doctors”, Crown Publishers, 2008